Future-proofing primary health care: GP recruitment and retention in the new NHS

WILL WE NEED MORE GPS IN THE FUTURE?

The answer is an unqualified yes. In an increasingly sub-specialised and de-centralised NHS we shall need high-quality generalists more than ever to provide coordination and continuity for patients; to manage risk, uncertainty, and cost; to lead service redesign through commissioning; and to work in partnership with other health and social care professionals. The Department of Health expects that 50% of newly qualified doctors each year should be recruited to general practice,2 but can we be sure that there will be a sufficient number of appropriately trained GPs available when we need them?

This month's BJGP presents three important and different papers raising concerns around the future recruitment and retention of GPs in the UK and beyond. Lambert and Goldacre,3 from the well-established UK Medical Careers Research Group in Oxford, present the results of a series of questionnaire surveys of UK medical graduates between 2000 and 2009 regarding their future career intentions. They found that only around 20% of doctors in their first year after qualification expressed a first choice career preference for general practice. This is far removed from the Department of Health's 50% target.

Numbers of medical graduates entering general practice appear to be in decline in several Western countries and Lorant et al4 report from Belgium on an interview survey of 102 key primary care stakeholders. Their study concludes that, while there is a consensus on the need for general practice reform to improve recruitment and retention, such reforms are likely to be difficult to implement in practice.

The potential imbalance between GP demand and supply is not confined to Europe. A recent paper in the Archives of Internal Medicine4 compared surveys of graduating US medical students in 1990 and 2007 which showed that the proportion of graduates planning to enter the US equivalent of primary care had fallen from 9% to 2% in the intervening years. The authors conclude that the US faces a ‘pending crisis’ due to a shortage in its primary care medical workforce, with 2007 students having higher debt, more negative perceptions of workload and stress, and less interest in pursuing a primary care career.

Australia is already suffering from a shortage of GPs, particularly in rural and remote areas where not only doctors but also other healthcare professionals are turning their backs on working there. Stevenson and colleagues interviewed 15 primary care doctors working in several areas of social disadvantage in Australia.6 They reach interesting conclusions as to what makes some doctors thrive in these challenging circumstances and go on to suggest how conditions might be promoted to improve recruitment and retention.

In the UK, the GP workforce is changing fast. Around 20% of GPs are over 55 years of age and large numbers may reasonably be expected to retire over the next 5 years.7 Over 60% of the UK GP trainee workforce is female, and this proportion is notably higher in some regions.8 Many of our future GPs are likely to want to work flexibly, and increasing numbers of GPs of both sexes are choosing to follow portfolio careers. All of these factors contribute to the need to attract more doctors to take up a career in general practice.

WHERE TO FROM HERE?

Perhaps there is hope that things will improve. Medical student numbers have increased from 30 600 in 2004 to 39 000 in 2010. General practice is now much more visible to students, with all medical schools now providing a significant proportion of teaching in the community. Such teaching often goes beyond traditional GP placements, with GPs providing a variety of innovative programmes of practice-based education in areas traditionally taught in secondary care.9

In the UK GP educators are now well represented in university departments of primary care and medical education, with increasing involvement in core activities such as curriculum development, assessment, and admissions. A national Heads of Teaching Group has recently formed within the Society for Academic Primary Care. The group is active in its aims to share good practice and provide a lobbying function in order to enhance the profile of undergraduate primary care education in all UK medical schools.

The postgraduate landscape has also evolved, with the aspiration of GP placements for up to 55% of foundation trainees (postgraduates in generic training post before specialisation). While some areas have achieved this target, the recent Collins Report on foundation training highlights the national reality that, on average, only 16% of foundation trainees are gaining experience of a GP attachment.10 Greater efforts must be made to provide most, if not all, foundation trainees with a meaningful experience of working in primary care, not least in order to inform their future career choices.

Attention must also be paid to adapting the structure of GP specialty training in line with the future needs of the discipline. Although the balance in training has shifted somewhat in recent years from hospital to community, the overall duration of the majority of programmes remains just 3 years. Many trainees still spend part of this time in posts which offer traditional hospital-based experience that may not reflect the context of new community-based service models. Furthermore, the constant pressure to produce evidence to demonstrate achievement of curriculum competencies and undertake assessments for certification are placing increased pressure on trainees within the 3-year period of training.

The case for extended training in general practice is strong, but it is also important to ensure that medical training across all specialties reflects the future needs of patients and populations. This requires joined-up thinking with respect to the commissioning and provision of medical education and training, to ensure appropriate workforce planning and a suitable balance in the numbers of generalists and specialists we produce for the future. The system as a whole must support students and trainees in making strategic career choices. Only in this way can we start to break down the traditional barriers between primary and secondary care and develop systems of truly integrated care to improve population health outcomes.